CNTC Newsletter – Fall 2009

A quarterly electronic newsletter from the Francis J. Curry National Tuberculosis Center (CNTC)

About CNTC

CNTC creates, enhances, and disseminates resources and models of excellence, and performs research to control and eliminate TB in the United States and internationally.

CNTC is designated by the Centers for Disease Control and Prevention (CDC) as the Regional Training and Medical Consultation Center (RTMCC) for the Western Region, serving Alaska, California (including Los Angeles, San Diego, and San Francisco), Colorado, Hawaii, Idaho, Montana, Nevada, Oregon, Utah, Washington, Wyoming, and the U.S. Pacific Island Territories.

Committed to the belief that everyone deserves the highest quality of care in a manner consistent with his or her culture, values and language, CNTC develops and delivers highly versatile, culturally appropriate trainings, educational products, medical consultation, and technical assistance.

CNTC Announces Three New Collaborative Projects

CNTC has joined with partners in the United States, Mexico, and the U.S.-Affiliated Pacific Islands to pursue projects that range from infection control training, to studying the use of interferon-gamma release assays in overseas pediatric screening, and developing standards for managing TB and diabetes.

CNTC recently participated in the launch of “TB Infection Control Assessment, Training, and Technical Assistance for Mexico” through the U.S. TB Regional Training and Medical Consultation Centers (RTMCCs) Pilot Project. CNTC is working closely with partners at the Southeastern National TB Center (SNTC RTMCC) and the CDC’s Division of TB Elimination (DTBE) on this project. At the August launch meeting in Mexico City, the U.S.-based team met with the head of the National Tuberculosis Control Program (NTP) in Mexico and representatives from the three Mexican states where the project will be piloted: Chiapas, Guanajuato, and Chihuahua.

CNTC is also involved in Task Order 31, Evaluation of Interferon Gamma Release Assays (IGRA) in Overseas Immigration Examination of Children in Moderate- and High-Burden Countries, an upcoming project funded by the CDC TB Epidemiologic Studies Consortium. This study aims to evaluate the role of IGRA in the overseas screening of children aged 2 to 14 years, and completeness and outcome of follow-up after arrival in the U.S. of children diagnosed with Class B2 latent TB infection (LTBI). As a subcontract to the Denver Health and Hospital Authority, CNTC will collaborate with the San Francisco, San Mateo, and Santa Clara TB programs to provide follow-up data of children who arrived in the three counties after they were diagnosed with LTBI overseas.

Under co-sponsorship of the CDC’s DTBE and Division of Diabetes Translation, CNTC has launched a project to develop standards for tuberculosis/diabetes mellitus (TB/DM) in the U.S.-Affiliated Pacific Islands (USAPI). Dr. Richard Brostrom - Medical Director and TB Controller for the Commonwealth of the Northern Marianas Islands, Dr. Gisela Schecter – Consultant, Dr. L. Masae Kawamura – Co-Principal Investigator at CNTC, and Pacific Island and national colleagues will develop standards of care for diagnosing and treating patients with this co-morbidity condition. The project was launched at the Pacific Islands TB Controllers Association meeting in Guam in October. In November, Dr. Brostrom will represent the project at an experts meeting of global TB and DM leaders in Paris.

New Online Resource for TB Diagnosis

The Stop TB Partnership's New Diagnostics Working Group (NDWG) announces a new website resource: Evidence-based Tuberculosis Diagnosis.

The website is a comprehensive source of evidence syntheses, policies, guidelines, and research agendas on TB diagnosis, providing access to all published systematic reviews on TB diagnostics, and several reports, monographs, training modules and slide presentations.

The website also offers: detailed guidance on how to conduct and report diagnostic research on TB and guidance on how to perform systematic reviews of diagnostics; tools on guideline development, including GRADE; and documents on improvement of laboratory quality and practice. All information is provided as open access, with no registration or fee requirements.

Contributors to the development of this comprehensive resource include the Foundation for Innovative New Diagnostics (FIND), the Special Programme for Research and Training in Tropical Diseases (TDR), the Global Laboratory Initiative (GLI), the Public Health Agency of Canada (PHAC), and CNTC. View Evidence-based Tuberculosis Diagnosis

TB Control in the Western Region

CNTC Newsletter is proud to periodically highlight TB control programs in CNTC’s Western Region of the United States. In this issue, we focus on the Los Angeles County TB Control Program.

Los Angeles (L.A.) County is famous worldwide for its entertainment industry, beaches, rich multicultural heritage, and freeways that criss-cross its 4,084 square miles in Southern California. With over 10 million residents living within 88 cities and a large unincorporated area, L.A. County is the most populous county in the nation, and 1 out of every 4 Californians live within its boundaries. If L.A. County was a nation, its economy would be among the top 20 of the world. Beyond its economic power lies a wealth of diversity. According to the County’s official website, the region’s melting pot contains 140 cultures in which 135 languages are spoken. Fully one-third of L.A. County’s population is foreign-born, and it is home to the largest numbers of Filipinos, Guatemalans, Koreans, Mexicans, Salvadorans and Thai descendents outside their native countries.

The sheer size and complexity of the County must have given Dr. Frank Alvarez pause when he considered succeeding long-time L.A. County TB Controller Annette Nitta, MD (who retired in 2008). However, as a Los Angeles native and local surfer who attended the University of Southern California, Dr. Alvarez was no stranger to the area and saw the career move as a return to his roots. As TB Controller and Deputy Health Officer for Santa Barbara County (a northern neighbor to Los Angeles) for 10 years, and San Mateo County (in Northern California) for 8 years previously, Dr. Alvarez was an experienced and accomplished TB clinician and administrator. He realized that the challenges of controlling TB disease and latent TB infection in Los Angeles are formidable, not to mention overseeing the work of 66 program staff working in 15 locations. Dr. Alvarez comments: “A critical challenge facing our TB Control Program is the dynamics of immigration throughout the various regions of L.A. County. It will be an ongoing priority to improve outreach and management of cases and contact investigations in these unique ethnic and cultural settings. This will have to be accomplished through a committed partnership with three administratively separate, yet essential, TB- focused service programs: TB Control Program, Community Health Services (direct TB clinic-based services), and the Department of Health Services (hospital-based services), as well as academic, and private-public partnerships.”

In 2008 Los Angeles County reported:

• 792 cases of active TB (8.1 per 100,000, or almost double the U.S. rate of 4.2 per 100,000). This represents a 2.8% decrease from 2007 (815 cases). Since 1999, there has been a steady decrease (32% overall) in the number of cases
• TB cases born outside of the U.S. comprised approximately 77% of L.A. County’s cases (compared to 58% nationally)
• 46% of the TB cases were Hispanics, 35% Asian, 11% Black, and 7% White
• 9% of TB isolates tested were resistant to INH; 1.1% were resistant to both INH and rifampin (MDR-TB), a figure similar to the national percentage

In 2006 the L.A. County TB Control Program partnered with several community organizations, such as Breathe California and the JWCH Institute, to form the Los Angeles County TB Coalition. The Coalition provides education and outreach to at-risk populations in the County, and ensures that TB is prominently profiled during events like World TB Day.

Although still relatively new to his role as TB Controller in Los Angeles County, Dr. Alvarez is well aware of the elements that will continue to ensure his program’s success: “Our program benefits from strong and experienced TB Nurse Managers, coordinating both hospital- and clinic-based case management, a talented Health Education Unit, and two very knowledgeable TB clinician specialists, engaged in MDR, as well as complex co-infected case consultations for the L.A. County TB clinic practitioners. We also benefit from the direct support of two very experienced CDC senior advisors, with experience in other large metropolitan and state TB programs (such as New York City and California). We are also engaged with the UCLA School of Public Health and Medicine, and always looking to educate and foster future public health professionals, and to promote local and global TB control efforts.”

Upcoming Products

By year’s end, watch for three new educational products that will provide valuable learning opportunities, resources, and tools for TB programs and providers: Tuberculosis Drug Information Guide; Tuberculosis fármacorresistente: una guía práctica para la atención médica del paciente; and Practical Solutions for TB Infection Control: Infectiousness and Isolation.

Tuberculosis Drug Information Guide is derived from “Chapter 4: Medication Fact Sheets” in Drug-Resistant Tuberculosis: A Survival Guide for Clinicians (2nd edition) produced in 2008 by CNTC and the State of California Department of Public Health, Tuberculosis Control Branch. Two additional drugs, ofloxacin and clarithromycin, have been included in the collection of twenty fact sheets that can assist any physician, nurse, or pharmacist who participates in the management of patients with TB or LTBI. Available on the CNTC website by December 31, 2009.

Drug-Resistant Tuberculosis: A Survival Guide for Clinicians (2nd edition) has also recently been translated into a Spanish-language version by the Southeastern National Tuberculosis Center (SNTC) in Florida. Tuberculosis fármacorresistente: una guía práctica para la atención médica del paciente will be available in print and electronic formats in December 2009. For more information, visit the SNTC website.

Practical Solutions for TB Infection Control: Infectiousness and Isolation is a 60-minute online course designed to provide healthcare workers with practical tips on determining if a TB patient is infectious, deciding whether to isolate the patient, and setting up effective measures to isolate the TB patient in the clinic and home settings. Available on the CNTC website by December 31, 2009.

Upcoming Training Courses

CNTC’s schedule of upcoming training courses (through March 2010) offers a variety of courses for clinicians and public health providers.

November 3-5, 2009
Ontario, CA
Tuberculosis Communicable Disease Investigator Intensive
Three-day course for communicable disease investigators (CDIs) who conduct tuberculosis contact investigations.

December 10, 2009
National Web-based Seminar
Tuberculosis and Diabetes
1.5-hour web-based seminar for clinicians in the United States who may treat or screen patients with tuberculosis, diabetes, or both diseases.

February 16-18, 2010
San Francisco, CA
TB Clinical Intensive
Three-day intensive for physicians and other licensed medical professionals who diagnose and treat tuberculosis.

March 16-19, 2010
San Francisco, CA
Case Management/Contact Investigation Intensive
Four-day training for nurses, communicable disease investigators, and medical social workers.

For periodic updates on additional trainings, complete course descriptions, and application forms, view our training section.

Mini-Fellowship Applications for 2010 Available Online

CNTC offers mini-fellowship trainings to TB care providers (MDs, nurses, support staff) from the western region of the U.S. to provide firsthand knowledge and experience in carrying out TB control activities. Mini-fellowships are designed to meet the individual needs of participants by assessing areas of practice and communities served, and matching identified objectives with appropriate activities. Learn more.

Nurse-to-Nurse Applications for 2011

CNTC’s Nurse-to-Nurse Training Program brings direct and customized training to nurses working in the field. Local jurisdictions that want to apply to host a 1-day course in 2011 will find applications available on the CNTC website in January 2010.

Faculty Profile

To better acquaint our readers with the corps of TB experts that comprise our training and medical consultation faculty, each issue of CNTC Newsletter presents a profile of a CNTC faculty member. In this issue we feature Henry F. Chambers, MD..

As a young student grappling with the periodic table of elements, it is unlikely that Henry “Chip” Chambers could foresee the distinguished career that awaited him. However, the young man interested in chemistry did indeed develop into one of the country’s leading specialists in bacterial infections, infection control, and antimicrobial resistance. In fact, in 2005 when the New England Journal of Medicine published two studies indicating that resistant strains of Staphylococcus aureus had moved beyond hospitals into community-acquired settings, the prestigious journal relied on Dr. Chambers to write its editorial on the alarming epidemic.

Henry Chambers was born in Lebanon, Kentucky. As an undergraduate, he studied chemistry at Centre College in Danville, Kentucky and graduated as class valedictorian. His education continued at Vanderbilt University School of Medicine in Nashville, where he was again class valedictorian and earned his medical degree.

Heading west, Dr. Chambers began his long affiliation with University of California, San Francisco (UCSF), where he was a resident, chief resident, and fellow in general medicine. His interest in infectious diseases began during his chief residency with the arrival of Dr. Merle Sande as Chief of Medicine at San Francisco General Hospital, which coincided with the appearance of AIDS as a completely new infectious disease. Following a post-doctoral research fellowship at Rockefeller University, Dr. Chambers joined the medical faculty of UCSF where he currently serves as Professor of Medicine, Chief of Infectious Diseases at San Francisco General Hospital, and Director of the UCSF Infectious Diseases Fellowship Training Program.

Dr. Chambers’ bibliography contains over 200 publications and textbook chapters, a clear testament to his tireless clinical work and research in the areas of drug resistance, endocarditis, bacterial infections, and staphylococcal diseases. As a longtime faculty member at San Francisco General Hospital he acquired a longstanding interest in – and healthy respect of – Mycobacterium tuberculosis, which he has characterized as a “uniquely durable human pathogen.” He is an international authority in antimicrobial therapy and treatment of infections caused by drug-resistance bacteria. His work on beta-lactam antibiotics as salvage agents for chemotherapy of drug-resistant tuberculosis is current today as extensively drug-resistant tuberculosis has emerged. In 2005, he was the lead author in tuberculosis studies examining the efficacy of the carbapenem, imipenem, in a mouse model of TB and in humans with MDR-TB.

Dr. Chambers was a founding member of the CNTC faculty in 1994, and with Dr. Charles Daley, helped to develop the Center’s core clinical intensive course. He has trained health providers on infection control and drug-resistance at CNTC courses, and regularly provides medical consultation to clinicians on the CNTC Warmline.

Dr. Chambers is a Fellow of the Infectious Diseases Society of America, an elected member in the American Society of Clinical Investigation, and Editor for Antimicrobial Agents and Chemotherapy. In 2009 Dr. Chambers’ distinctions continue to accrue: in April he was chosen as a Fellow of the American College of Physicians.

Dr. Daley, now Head of the Division of Mycobacterial and Respiratory Infections at National Jewish Health in Denver, describes the lasting impression Dr. Chambers made during their years working together at UCSF: "Chip has always been an inspiration and role model to me. In consultations he provides a great combination of impressive clinical acumen, common sense, and humor. Chip is an outstanding physician and scientist, and his love for his work is truly infectious (really!)"

Find CNTC on Facebook

CNTC has recently joined Facebook. The CNTC page is an interactive forum that combines information from our website, list serv announcements, and photos of our staff. If you have a Facebook account, click on “become a fan” to receive our messages and updates directly. We encourage you to post your questions, comments, discussion items, and your own TB-related photos. The group of CNTC “fans” is also a great way to expand your professional network. (We recognize that not all users have access to Facebook at their places of work.) Visit CNTC’s Facebook page.

Contact Us

Francis J. Curry National Tuberculosis Center
3180 18th Street, Suite 101
San Francisco, CA 94110-2028
Telephone: 415-502-4600
Fax: 415-502-4620
Warmline TB medical consultation: 877-390-6682 (toll-free) or 415-502-4700
tbcenter@nationaltbcenter.ucsf.edu
www.nationaltbcenter.ucsf.edu

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CNTC Newsletter

CNTC Principal Investigator: Philip C. Hopewell, MD
RTMCC Co-Principal Investigators: Philip C. Hopewell, MD, and L. Masae Kawamura, MD
Task Order #1 Principal Investigators: Philip C. Hopewell, MD
Task Order #19 Co-Principal Investigators: Elizabeth Fair, PhD, and Christine Ho, MD
RTMCC Medical Director: Lisa Chen, MD
CNTC Director: Tom Stuebner, MSPH
Training Administrator: James Sederberg
Research Administrator: Baby Djojonegoro, MS, MPH
CNTC Newsletter Editor: Kay Wallis, MPH
CNTC Web Developer: Mari Griffin, MS